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1.  Physicians’ beliefs about breast cancer surveillance testing are consistent with test overuse 
Medical care  2013;51(4):315-323.
Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians’ breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs.
2009–2010 cross-sectional survey of US medical oncologists and primary care physicians (PCPs). Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices.
1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs (95% CI: 81.4%–86.5%) and 72% of oncologists (95% CI: 69.8%– 74.7%) reported beliefs consistent with blood test overuse, while 50% of PCPs (95% CI: 47.3%– 53.8%) and 27% of oncologists (95% CI: 23.9%–29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care.
Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.
PMCID: PMC3596481  PMID: 23269111
2.  Patient and Provider Factors Associated with Colorectal Cancer Screening in Safety Net Clinics Serving Low-income, Urban Immigrant Latinos 
Journal of health care for the poor and underserved  2012;23(3):10.1353/hpu.2012.0109.
Latinos have lower colorectal cancer screening rates than Whites.
We reviewed a random sample of charts between July 2009 and February 2010 of safety-net clinic of 840 immigrants (50 years and older) from Central and South America receiving care. Logistic regression evaluated associations of ever vs. never screening, patient and physician factors.
Ever screening rates were 24.5%, and only 17% of charts noted a physician screening recommendation. However, the odds of screening were 9.89 times higher (95% CI: 6.25–15.64, p<.001) among patients with a physician recommendation vs. those without, considering covariates. The odds of screening were 0.61 times lower (95% CI: 0.40–0.92, p=.02) in patients with a body mass index ≥ 30 vs. <30.
While rates were low, determinants of screening were similar in this Latino subgroup to those reported in other Latino and non-Latino populations. Low rates of documented physician screening recommendations may indicate a potential missed opportunity for cancer control in safety-net clinics.
PMCID: PMC3824152  PMID: 24212154
Latinos; colorectal cancer; screening; immigrants; obesity
3.  Racial Differences in Colorectal Cancer Survival in the Detroit Metropolitan Area 
Cancer  2009;115(16):3791-3800.
Colorectal carcinoma is the second most common cause of cancer death with African Americans having lower survival compared with White Americans. The purpose of this study was to investigate the effect of demographics, clinical factors, and socioeconomic status (SES) on racial disparities in colorectal cancer survival in the Detroit Metropolitan Area.
The study population included 9078 individuals with primary invasive colorectal cancer identified between 1988 and 1992 through the Surveillance, Epidemiology, and End Results (SEER) program. Demographics, clinical information, and survival were obtained through SEER. SES was categorized using occupation, educational level, and poverty status at the census tract level. Kaplan-Meier survival curves and Cox proportional hazards regression were used to compare overall survival by race.
African Americans were more likely to be diagnosed with stage IV disease (P < .001), and to reside within poor census tracts (P < .001) compared with White Americans. Unadjusted analysis showed that African Americans had a significantly higher risk of death compared with their White American counterparts (hazards ratio [HR], 1.13; 95% confidence interval [CI], 1.07–1.20). After adjusting for age, marital status, sex, SES group, TNM stage, and treatment, race was no longer significantly associated with overall survival (HR, 1.00; 95% CI, 0.92–1.09). Similar results were seen with colorectal cancer-specific survival.
Racial disparities in colorectal cancer survival dissipate after adjusting for other demographic and clinical factors. These results can potentially affect medical guidelines regarding screening and treatment, and possibly influence public health policies that can have a positive impact on equalizing racial differences in access to care.
PMCID: PMC3799766  PMID: 19598220
survival; colorectal cancer; SEER; racial disparities; socioeconomic status
4.  Racial Differences in Cervical Cancer Survival in the Detroit Metropolitan Area 
Cancer  2008;112(6):1264-1271.
African-American (AA) women have lower survival rates from cervical cancer compared with white women. The objective of this study was to examine the influence of socioeconomic status (SES) and other variables on racial disparities in overall survival among women with invasive cervical cancer.
One thousand thirty-six women (705 white women and 331 AA women) who were diagnosed with primary invasive cancer of the cervix between 1988 and 1992 were identified through the Metropolitan Detroit Cancer Surveillance System (MDCSS), a registry in the Surveillance, Epidemiology, and End Results (SEER) database. Pathology, treatment, and survival data were obtained through SEER. SES was categorized by using occupation, poverty, and educational status at the census tract level. Cox proportional hazards models were used to compare overall survival between AA women and white women adjusting for sociodemographics, clinical presentation, and treatment.
AA women were more likely to present at an older age (P < .001), with later stage disease (P < .001), and with squamous histology (P = .01), and they were more likely to reside in a census tract categorized as Working Poor (WP) (P < .001). After multivariate adjustment, race no longer had a significant impact on survival. Women who resided in a WP census tract had a higher risk of death than women from a Professional census tract (P = .05). There was a significant interaction between disease stage and time with the effect of stage on survival attenuated after 6 years.
In this study, factors that affected access to medical care appeared to have a more important influence than race on the long-term survival of women with invasive cervical cancer.
PMCID: PMC3799770  PMID: 18257090
cervical cancer; survival; race; socioeconomic status; Surveillance; Epidemiology; End Results
5.  Use of Imputed Population-based Cancer Registry Data as a Method of Accounting for Missing Information: Application to Estrogen Receptor Status for Breast Cancer 
American Journal of Epidemiology  2012;176(4):347-356.
The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program provides a rich source of data stratified according to tumor biomarkers that play an important role in cancer surveillance research. These data are useful for analyzing trends in cancer incidence and survival. These tumor markers, however, are often prone to missing observations. To address the problem of missing data, the authors employed sequential regression multivariate imputation for breast cancer variables, with a particular focus on estrogen receptor status, using data from 13 SEER registries covering the period 1992–2007. In this paper, they present an approach to accounting for missing information through the creation of imputed data sets that can be analyzed using existing software (e.g., SEER*Stat) developed for analyzing cancer registry data. Bias in age-adjusted trends in female breast cancer incidence is shown graphically before and after imputation of estrogen receptor status, stratified by age and race. The imputed data set will be made available in SEER*Stat ( to facilitate accurate estimation of breast cancer incidence trends. To ensure that the imputed data set is used correctly, the authors provide detailed, step-by-step instructions for conducting analyses. This is the first time that a nationally representative, population-based cancer registry data set has been imputed and made available to researchers for conducting a variety of analyses of breast cancer incidence trends.
PMCID: PMC3491971  PMID: 22842721
breast neoplasms; imputation; incidence; missing data; receptors, estrogen
6.  Evaluation of Hypertension as a Marker of Bevacizumab Efficacy 
Predictive factors for efficacy of vascular endothelial growth factor pathway-targeted therapies have not been identified or confirmed. Hypertension has been observed as a side effect to anti-vascular endothelial growth factor therapy. The goal of our study was to retrospectively assess if hypertension induced during treatment with bevacizumab was associated with clinical outcome in metastatic colorectal cancer patients treated with bevacizumab.
Patients and methods
We conducted a retrospective chart review of patients with colorectal cancer treated with bevacizumab at Lombardi Comprehensive Cancer Center from 2004 to 2008.
Eighty-four patients with metastatic colorectal cancer were eligible. Eighteen patients (21%) developed grades 3 hypertension. Twelve patients (14%) developed grade 2 hypertension. Six patients (7%) developed grade 1 hypertension. Median overall survival (OS) was 29 months and progression-free survival (PFS) was 10 months. Patients with any grade hypertension while on bevacizumab had an adjusted hazard ratio for death of 0.32 (p=0.03) and adjusted risk of progression of 51% (p=0.02) compared to those without hypertension (HTN). When stratified by metastatic disease, patients presenting with metastases who developed HTN had better OS and PFS (p=0.03 and 0.01.) Among patients without metastases at diagnosis, those with HTN on bevacizumab had better OS and PFS but results were not statistically significant (p=0.60 and 0.62, respectively).
Our data indicate that bevacizumab-induced hypertension may represent an interesting prognostic factor for clinical outcome in advanced colorectal cancer patients receiving bevacizumab.
PMCID: PMC3704163  PMID: 19921473
bevacizumab; colorectal cancer; hypertension
7.  Information Channels Associated with Awareness of Human Papillomavirus Infections and Vaccination among Latino Immigrants from Safety Net Clinics 
We report on information channels associated with awareness about human papillomavirus (HPV) among immigrant Central and South American Latinos.
We conducted a survey of 1334 Latino ≥21 years attending safety-net clinics in 2007–2008. Logistic regression analyses evaluated associations with HPV awareness.
Forty-eight percent were aware of HPV infection and 40% were aware of the vaccine. Spanish television (38%) and providers (23%) were the primary HPV information sources. Infection awareness was associated with internet use (OR 1.47; 95% CI 1.10–1.96) and self-efficacy to find health information (OR 1.19; 95% CI 1.08–1.30). Vaccine awareness was associated with media use for health information (OR 1.27; 95% CI 1.09–1.49) and internet use (OR 1.59; 95% CI 1.18–2.13).
Although Spanish television has reached this low HPV awareness group, there may be missed opportunities for education by providers. Television and the internet may also be effective channels for future interventions.
PMCID: PMC3567193  PMID: 22089978
Human Papillomavirus; Latinos; Cervical Cancer; Health Communication; Vaccine
8.  Assessing the awareness of and willingness to participate in cancer clinical trials among immigrant Latinos 
Journal of community health  2012;37(2):335-343.
There is a paucity of data on determinants of clinical trial participation in the growing and diverse US Latino population. We describe correlates of awareness of and willingness to participate in clinical trials among Central and South American Latinos using safety net clinics.
We conducted an interviewer administered, Spanish language cross-sectional survey (n=944). Logistic regression was used to assess effects of health information sources and psychosocial variables on awareness of clinical trials and intention to participate in clinical trials.
While only 48% knew what a clinical trial was, when explained, 65% indicated a willingness to participate in a trial. Providers were the most common source of general health information. Use of Internet for health information (OR = 2.33, 95% CI 1.63, 3.34, p = .001), trust in health information (OR = 1.33, 1.12, 1.58 for each one unit increase, p = .001) and higher education each independently increased the odds of clinical trial awareness, but obtaining information from providers did not. Contacting the Cancer Information Service (OR = 2.49, 95% CI 1.01, 6.14, p = .05) and psychosocial factors (e.g., greater worry, higher self-efficacy and trust in information) were each independently associated with intent to join a clinical trial but demographic factors were not.
Several information channels, including the Internet and telephone call centers appear to be effective in conveying information about clinical trials. While providers were cited as the most common source of health information, this source was not associated with clinical trial knowledge or intent to participate in trials suggesting a missed opportunity for communication to this immigrant Latino population.
PMCID: PMC3567194  PMID: 21805372
Clinical trial awareness; clinical trial participation; Latinos; mass media
9.  Internet Access and Online Cancer Information Seeking Among Latino Immigrants From Safety Net Clinics 
Internet use is widespread, but little is known about Internet use for cancer information among Latinos, especially those who rely on safety net clinics. The authors investigated access to and intended use of the Internet for cancer information among low income, immigrant Latinos predominately from Central and South America. A cross-sectional study of 1,273 Latinos 21 years and older attending safety net clinics or health fairs was conducted from June 2007 to November 2008. The authors used logistic regression models to evaluate associations of age, acculturation, psychosocial factors and other covariates with Internet access and intended use of the Internet for cancer information among those with access. Of the sample, 44% reported Internet access. Higher information self-efficacy and greater trust in the Internet were independently associated with Internet access (p= .05 and p < .001, respectively). Among those with access, 53.8% reported they intended to seek cancer help online if they needed information. Those with younger age and higher acculturation, education and self-efficacy had higher odds of intended Internet use for cancer information, considering covariates. In addition, those with high (vs. low) perceived risk of cancer (OR = 1.76; 95% CI [1.14, 2.73]; p = .01) and higher levels of trust in online health information (OR = 1.47 per one-point increase; 95% [CI 1.19, 1.82]; p = .0004) were more likely to intend to seek cancer information online. These findings that Internet access is fairly high in the immigrant Latino population and that the Internet is a trusted source of cancer information suggest that the Internet may be a channel for cancer control interventions.
PMCID: PMC3555511  PMID: 23066874
10.  Annual Report to the Nation on the Status of Cancer, 1975–2009, Featuring the Burden and Trends in Human Papillomavirus (HPV)–Associated Cancers and HPV Vaccination Coverage Levels 
The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updates on cancer incidence and death rates and trends in these outcomes for the United States. This year’s report includes incidence trends for human papillomavirus (HPV)–associated cancers and HPV vaccination (recommended for adolescents aged 11–12 years).
Data on cancer incidence were obtained from the CDC, NCI, and NAACCR, and data on mortality were obtained from the CDC. Long- (1975/1992–2009) and short-term (2000–2009) trends in age-standardized incidence and death rates for all cancers combined and for the leading cancers among men and among women were examined by joinpoint analysis. Prevalence of HPV vaccination coverage during 2008 and 2010 and of Papanicolaou (Pap) testing during 2010 were obtained from national surveys.
Death rates continued to decline for all cancers combined for men and women of all major racial and ethnic groups and for most major cancer sites; rates for both sexes combined decreased by 1.5% per year from 2000 to 2009. Overall incidence rates decreased in men but stabilized in women. Incidence rates increased for two HPV-associated cancers (oropharynx, anus) and some cancers not associated with HPV (eg, liver, kidney, thyroid). Nationally, 32.0% (95% confidence interval [CI] = 30.3% to 33.6%) of girls aged 13 to 17 years in 2010 had received three doses of the HPV vaccine, and coverage was statistically significantly lower among the uninsured (14.1%, 95% CI = 9.4% to 20.6%) and in some Southern states (eg, 20.0% in Alabama [95% CI = 13.9% to 27.9%] and Mississippi [95% CI = 13.8% to 28.2%]), where cervical cancer rates were highest and recent Pap testing prevalence was the lowest.
The overall trends in declining cancer death rates continue. However, increases in incidence rates for some HPV-associated cancers and low vaccination coverage among adolescents underscore the need for additional prevention efforts for HPV-associated cancers, including efforts to increase vaccination coverage.
PMCID: PMC3565628  PMID: 23297039
11.  Metabolism of isothiocyanates in individuals with positive and null GSTT1 and M1 genotypes after drinking watercress juice 
Background & Aims
Isothiocyanates (ITCs) derived from cruciferous vegetables have been shown to be promising agents against cancer in human cell culture, animal models, and in epidemiological studies. Several epidemiological studies have demonstrated an inverse relationship between intake of dietary isothiocyanates and the risk of cancers, particularly lung, colon, and breast. More importantly, the protective effects of dietary ITCs appear to be influenced by glutathione S-transferase (GST) genotype; specifically, individuals with glutathione S-transferase theta 1 (GSTT1) and glutathione S-transferase Mu 1 (GSTM1) null are better protected than those with GSTT1 and M1 positive. Although majority of studies, especially those conducted in populations exposed to ITCs rich diet, demonstrated such effects there are a few studies showed opposite or no association. While evidence for the interactions of dietary ITCs with GST genes is relatively strong, the reasons for the differential effects remain unclear. In this study, we examined one possible mechanism whether subjects with the null genotypes excrete ITCs at a slower rate than those with the positive genotypes after drinking watercress juice, a rich source of ITCs.
A total of 48 subjects, 28 GSTT1 and M1 positive and 20 null genotypes were enrolled in the study. The rates of excretion were determined using five urine samples collected over a period of 24 hours after drinking watercress juice.
No statistically significant differences in the rates of isothiocyanate excretion and the time of peak excretion were observed between the two tested groups with positive and null genotypes.
GSTT1 and M1 genotypes are not likely to be involved in the rate of excretion of ITCs in watercress. The demonstrated differences in protection among subjects with the two genotypes are not likely due to differences in overall ITC excretion rates, however, excretion rates of ITCs other than PEITC need to be investigated. Other yet to be identified mechanism(s) may underlie the diet and gene interactions between dietary ITCs and GST genotypes in human cancer prevention. Further research is needed to evaluate the protective mechanisms of isothiocyanates against cancer.
PMCID: PMC2987275  PMID: 20656381
isothiocyanates; watercress; PEITC; GST genotype; cancer prevention
12.  Breast Cancer Adjuvant Chemotherapy Decisions in Older Women: The Role of Patient Preference and Interactions With Physicians 
Journal of Clinical Oncology  2010;28(19):3146-3153.
Breast cancer chemotherapy decisions in patients ≥ 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.
Older women (n = 934) diagnosed with invasive (≥ 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).
Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of ≤ 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).
Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.
PMCID: PMC2903313  PMID: 20516438
13.  Stress Biomarkers in Medical Students Participating in a Mind Body Medicine Skills Program 
Georgetown University School of Medicine offers an elective Mind-Body Medicine Skills (MBMS) course to medical students to promote self-care and self-awareness. Participating medical students reported better management of academic stress and well-being than non-participants. In this study, we sought to assess the stress-reducing effects of MBMS by measuring physiological changes in first-year medical students. Saliva samples were collected before (January, time 1 (T1)-pre-intervention) and upon completion of the course (May, time 2 (T2p)-post-intervention), as well as from non-participating medical students (May, time 2 (T2c)-control). The T2p and T2c collections coincided with the period of final examinations. Cortisol, dehydroepiandrosterone-sulfate (DHEA-S), testosterone and secretory immunoglobulin A (sIgA) were measured. The mean morning salivary cortisol at T2p was 97% of the mean at baseline T1 which was significantly lower than for T2c (2.4) (95% confidence interval (CI) 0.57–1.60, P =  .001); DHEA-S showed similar pattern as cortisol where the T2p levels were significantly lower than T2c (P <  .001) in both morning and evening collections. Testosterone ratio at T2p (0.85) was also lower than T2c (1.6) (95% CI 0.53–1.3, P =  .01). sIgA levels were not statistically different. On direct comparison, the T2c and T2p means were significantly different for all cortisol, DHEA-S and testosterone values. Participants maintained their hormonal balance within the normal range throughout the academic semester while the control group showed significantly increased levels, probably exacerbated by the end of the semester exam stress. To our knowledge, this is the first study to assess the physiologic benefits of a MBMS program in medical students.
PMCID: PMC3137844  PMID: 21799696
14.  Socioeconomic and Psychosocial Gradients in Cardiovascular Pathogen Burden and Immune Response: The Multi-Ethnic Study of Atherosclerosis 
Brain, behavior, and immunity  2008;23(5):663-671.
The biologic mechanisms linking socioeconomic position and psychosocial factors to cardiovascular disease (CVD) are not well understood. Immune response to persistent pathogens may be one of these mechanisms.
We analyzed cross-sectional data from the Multi-Ethnic Study of Atherosclerosis (N=999) composed of adults age 45–84. Log-binomial regression and ordinal logistic regression models were used to examine associations of socioeconomic factors and psychosocial factors with pathogen burden and immune response among those infected. Pathogen burden was assessed based on seroprevalence of Helicobacter pylori, cytomegalovirus, herpes simplex virus-1, and Chlamydia pneumoniae and antibody levels were used to characterize high immune response to all four pathogens.
Low education was a strong and significant independent predictor of higher pathogen burden after adjustment for covariates (adjusted odds ratio (OR) 95% confidence interval (CI) 1.37, 1.19–1.57). Among subjects seropositive for all four pathogens, low education and a higher level of chronic psychosocial stress showed a positive association with higher antibody response, although associations were no longer significant in models with all covariates included (OR = 1.64, 95%CI 0.82–3.31 for lowest vs. highest educational category and OR= 1.29, 95%CI 0.96–1.73 for a one level increase in chronic stress).
Pathogen burden and heightened immune response may represent a biological pathway by which low socioeconomic position and chronic stress are related to increased rates of cardiovascular disease.
PMCID: PMC2694852  PMID: 19150399
Infection; inflammation; epidemiology; cardiovascular diseases
15.  Decreased Risk of Squamous Cell Carcinoma of the Head and Neck in Users of Nonsteroidal Anti-Inflammatory Drugs 
We evaluated the chemopreventive effect of nonsteroidal anti-inflammatory drug (NSAID) use in head and neck squamous cell carcinomas (HNSCC) by conducting a case-control study based on the administration of a standardized questionnaire to 71 incident HNSCC cases and same number of healthy controls. NSAID use was associated with a 75% reduction in risk of developing HNSCC. A significant risk reduction was noted in association with frequency of NSAID use. Restricting the analysis to aspirin users revealed a significant 90% reduction in risk of developing HNSCC. This study provides evidence for a significant reduction in the risk of developing HNSCC in users of NSAIDs, and specifically aspirin users.
PMCID: PMC2902018  PMID: 20628564
16.  Safety of Chronic Low-Dose Capecitabine as Maintenance Therapy in Gastrointestinal Cancers 
Maintenance chemotherapy is not routinely used in gastrointestinal (GI) cancers. Capecitabine is an oral formulation that is enzymatically converted to 5-fluorouracil preferentially in tumor tissue. We hypothesize that capecitabine could be used as a long-term maintenance therapy to improve outcomes in patients with high-risk GI cancers following standard chemotherapy regimens.
We conducted a retrospective study to assess the toxicity of maintenance capecitabine in 28 patients with a variety of advanced GI malignancies. Capecitabine 1,000 mg twice daily without interruption was used for the first 11 patients. The dose was reduced to 1,000 mg twice daily 5 days per week in 8 patients who developed hand-foot syndrome. The remaining patients began treatment on the same abbreviated schedule. All documented clinical adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (v3.0, 2003).
Main toxicities were grade 1/2 fatigue and hand-foot syndrome. Only one grade 3 toxicity was observed and no grade 4 toxicities were seen. We also observed a significant increase in red blood cell mean corpuscular volume in participants, which may have potential use as a biomarker to monitor therapeutic response.
Fixed therapeutic doses of oral capecitabine 1,000 mg twice daily, 5 days on, 2 days off, can be administered chronically with a high level of safety and should be explored in larger prospective studies to demonstrate efficacy in GI malignancies, especially pancreatic and metastatic colorectal cancers.
PMCID: PMC2739638  PMID: 19742139

Results 1-16 (16)